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IMPLEMENTATION OF THE MONTESSORI PROGRAM IN ASSISTED LIVING: POSITIVE OUTCOMES AND CHALLENGES

 

J. Brush1, N. Douglas2, M. Bourgeois3

 

1. Brush Development, Chardon, OH, USA; 2. Central Michigan University, Mount Pleasant, MI, USA; 3. University of South Florida, Tampa, FL, USA.  Corresponding author: Jennifer Brush, Brush Development, 9935 Campton Ridge Drive, Chardon, OH 44024, jennifer@BrushDevelopment.com, 440-289-0037

Jour Nursing Home Res 2018;4:42-48
Published online November 19, 2018, http://dx.doi.org/10.14283/jnhrs.2018.9

 


Abstract

The purpose of this study was to evaluate the impact of the implementation of the Association Montessori Internationale (AMI) Montessori for Dementia and Aging (1) (MDA) program in a memory care Assisted Living community. A pre-post quasi experimental descriptive study was conducted with 29 elders in an assisted living community. The AMI MDA program1 was implemented over the course of one year; adoption of program features was documented pre- and post-implementation. Outcomes for elders included number of neuropsychiatric symptoms due to dementia (Cohen-Mansfield Agitation Inventory (2)), falls, medications and hospitalizations; attitude, attention and engagement (Observational Measure of Engagement (3)), affect (Observed Emotion Rating Scale (4)); and the Dementia Quality of Life Scale (5). The Benjamin Rose Nurse Assistant Job Satisfaction Scale (6) was used to measure employee job satisfaction before and after implementation of the program. After 1 year, the community had adopted 68% of program features compared to 28% at study start. Elders displayed significantly more positive emotions, affect, and feelings of self-esteem and belonging after the intervention; positive trends were documented for increased engagement. Overall, employee job satisfaction was higher after the implementation of the program; barriers to full implementation, however, were identified.

Key words: Montessori, aging, dementia, assisted living.


 

Introduction

A new person-centered approach for long-term care and aging in place communities, AMI Montessori for Dementia and Aging (1) extends the tenets of person-centered care by focusing on the abilities, needs, interests, and strengths of persons with dementia. This innovative team approach creates worthwhile and meaningful roles, routines, and activities for the person within a supportive physical environment. Montessori’s philosophy was to enable persons to be as independent as possible, to have a meaningful place in their community, to possess high self-esteem, and to have the chance to make meaningful contributions to their community. The purpose of this study was to evaluate the impact of the implementation of the AMI MDA (1) program on elder and staff outcomes in a memory care Assisted Living community. The AMI MDA program was created based on the pedagogical philosophy of Dr. Maria Montessori and evidenced based person-centered approaches (7) to dementia care.  The merging of the two disciplines results in a person-centered approach to life that addresses the cognitive, physical, spiritual, social and emotional needs of elders and those living with dementia. This approach facilitates changes to the way one interrelates with elders and people with dementia by improving the quality of interactions.  The goal of the program was to form and maintain a caring community that is aligned with elders’ needs, interests, and abilities by creating an environment that is carefully prepared to provide opportunities for success, choice, enhanced independence and self-initiated activity. Elders’ lives are therefore enriched through the engagement in roles, routines and activities, fostering a sense of community belonging and well-being.
The AMI Montessori for Dementia and Aging Advisory Board has established standards and quality indicators for the application of Montessori in an aged care setting (1).  The standards address three critical areas of program implementation: leadership; staff; and the prepared environment.  In a community that has fully implemented this philosophy, the organizsation’s leadership encourages elders to be actively involved in the decision making related to daily life.  Multi-disciplinary teams are created, with a commitment to working together, with the purpose of meeting the needs of each person in their care.  In addition, the organization’s leadership uses effective communication tools to give staff, families, and elders a full understanding about the Montessori approach. There are financial commitments to budget allocations for best practice resources and staff training is conducted by a certified AMI Montessori for Dementia and Aging Educator. There is a formal commitment to continuous improvement of the implementation of MDA.  For instance, staff collect, maintain and use a comprehensive individual profile of needs, interests and strengths. Through collaboration with elders and their families, staff actively seek out and create opportunities for elders to act independently, exercise choice, move about with freedom and engage in activities of interest. Throughout the day, observation is utilized as a key tool for reflection and identification of individual needs. The environment must be visually organized and aesthetically pleasing. Shared spaces in the care community must provide enticement to engage by having dedicated, interactive areas allocated for activities. A Montessori community has evidenced-based cues and modifications in the environment to support independence. The environment should offer a full complement of appropriate multisensory materials, resources and activities that are accessible at any time.

Study Purpose

The purpose of this project was to implement and evaluate the AMI MDA program in a memory care Assisted Living community.  The program had the following goals:
1. Demonstrate implementation of the MDA program by increasing the adoption of environmental, staff, and leadership features of the program.
2. Increase elder engagement in purposeful activities, improve sense of well-being, improve affect, reduce psychotropic medication use, hospitalizations and falls, and reduce occurrence of neuropsychiatric symptoms due to dementia.
3. Increase staff job satisfaction.

 

Methods

The Institutional Review Board of Ideas Institute approved all study procedures and consent forms. This study utilized a pre-post, quasi-experimental design to implement and evaluate outcomes of the MDA program in one Midwestern assisted living in the United States. The assisted living is part of a non-profit continuing care retirement community housed on two campuses that includes independent and assisted living as well as skilled nursing.  The assisted living area contains 42 private bedrooms and shared activity, dining and living room spaces.

Participants

Study participants were (1) 29 elders with dementia or other cognitive impairment who resided in the community and (2) 22 employees of the assisted living community. An introductory letter and consent form was sent to the person holding durable power of attorney for each elder in the community.  After receipt of the signed consent form, the authors reviewed the elder’s medical chart; completed a communication, cognitive and reading screening of the elder; conducted an observation during their daily activities; and completed the quality of life assessment. Participants who were employees of the assisted living community provided informed consent to complete the following: 1) a job satisfaction survey (6); and 2) a rating of the elder’s neuropsychiatric symptoms (2) throughout the course of 2-weeks.

Measures

Measures used to collect data from participants who were elders with dementia or other cognitive impairment included: 1) chart review confirming diagnosis of dementia or other cognitive impairment; frequency of hospitalizations, falls, neuropsychiatric symptoms due to dementia and medications per nursing notes in the six months before and 3 months after implementation of the program; 2) informal communication screening (8)) and reading screening (9)) ; 3) the Montréal Cognitive Assessment  (MoCA) (10); 4) the Observational Measure of Engagement (3); 5) the Observed Emotion Rating Scale (4)); and, 6) the Dementia Quality of Life Scale (5). Employee participants completed the Benjamin Rose Nurse Satisfaction Survey (6), and the Cohen-Mansfield Agitation Inventory (2) for elder participants in the study. Lastly, a program implementation checklist adapted from AMI MDA standards (Table 1) was also completed to assess program fidelity and measure specific elements of program implementation. All of these measures with the exception of the informal communication screening, reading screening and MoCA were re-administered post- implementation and are described in more detail below.

 

After informed consent was completed, the second author reviewed each participant’s medical record to confirm diagnosis of cognitive impairment or dementia related disorder. The number of current medications, falls and hospitalizations was also recorded in the prior 6 months pre-implementation (6-months prior to implementation month 1) and at 3- months post-implementation. Finally, nursing notes were reviewed by the second author to assess frequency of neuropsychiatric symptoms due to dementia in the prior 6 months pre-implementation (6-months prior to implementation month 1) and at 3-months post-implementation. Neuropsychiatric symptoms due to dementia were defined as events that were significant enough for the nursing staff to record in a log and included violence toward other elders, inappropriate sexual advances toward other elders and verbal lashing out toward care partners.
The informal communication screening (8) was administered to each elder as well. The participant was asked his or her age, primary language, and they were observed as to whether or not they had glasses and/or hearing aids. During this process, elders were asked to about their education, hobbies, former occupation, likes and dislikes. The researchers observed conversational features of the elder including the ability to maintain topic, to initiate new topics, to request clarification, to take turns and ask questions. Researchers also noted if the elder was verbal at the single word, short phrase, few sentences or many sentences level. A reading screening was then conducted with each elder (9). Elders were assessed according to the optimal font for oral reading and reading for following simple, 1-step directions.
The MoCA (10) was completed with each elder for descriptive purposes only. The MoCA is a well-studied cognitive screener assessing visuospatial and executive functioning, naming, memory, attention, language, abstraction, delayed recall and orientation. Normal cognitive functioning is considered to be a score of 26 or higher out of 30 possible points, adding an additional point for any individuals who have 12 years of education or less.

The Observational Measure of Engagement (3) involved the investigators rating each elder according to ‘Attention’ and ‘Attitude’ during a 5-minute observation of the elder during an activity. Attention was rated on a 4 point Likert scale where 1 corresponds to ‘not attentive’ and 4 corresponds to ‘very attentive’. Attitude was ranked on a 7 point Likert scale, ranging from 1 (very negative) to 7 (very positive). Inter-rater reliability for this measure was reported to be 84% for engagement outcome measures (3).
The Observed Emotion Rating Scale (4) was completed for each elder as well. The investigators ranked elders according to their facial affect and other qualities that display either negative emotions or positive emotions. The maximum score for the display of both positive and negative emotions is 5, corresponding to the idea that the participant strongly displays that emotion. The minimum score for the display of both positive and negative emotions is 1, corresponding to the idea that the participant never displays that emotion. Kappa reliability for each of these emotion ratings was reported to be .76 or higher and validity, and validity estimates were also deemed supportive of the measure.
The Dementia Quality of Life Scale (5) is a self-report measure of 5-constructs of quality of life: positive affect, negative affect, feelings of self-esteem, feelings of belonging, and experience of aesthetics. Visual supports, including a 24-point type size rating scale and captioned pictures representing the topic of the questions, were used to support communication during the administration of this measure. Internal consistency of all constructs was reported to be .67 or higher
The Benjamin Rose Nurse Assistant Job Satisfaction Scale (6) was administered as a measure of job satisfaction before and after implementation of the program. A score of 0 reflects a highly dissatisfied employee and a score of 3 reflects a highly satisfied employee. This measure has been shown to demonstrate appropriate validity and reliability of .92 (6).
The Cohen-Mansfield Agitation Inventory (2) was completed by employee participants for all participants at pre-and post-implementation of the program. Familiar staff rated levels of agitation for 29 types of physical and verbal aggressive and non-aggressive behavior. While there are subscales to this measure, for the purposes of this study, participants were given an overall agitation score, ranging from 150 (maximum agitation) to 29 (minimum agitation). Cronbach’s alpha for this measure was reported to be .86, .91 and .87 for raters (2).
A Program Implementation Checklist adapted from the AMI MDA standards was developed to record the frequency of the program features/standards in place before and after the program was implemented.  As shown in Table 1, three standards areas were assessed: Leadership (7 features), Staff (9 features) and Prepared Environment (6 features), for a total of 88 required components of a fully implemented program. Each feature was observed to be:  0=Not at all implemented; 1=started to be implemented; 2=moderately implemented; 3=mostly implemented; 4=fully implemented.

Data Analysis

All raw data was entered into Microsoft Excel and later SPSS 24. Descriptive data analysis of all variables included means, standard deviations and ranges of responses. Pre-post and paired sample t-test comparisons were conducted as appropriate.

Implementation of Montessori Program Procedures

After obtaining consent for the elder participants, and collecting the pre-implementation measures the project began with a two-day educational workshop by the first author; 80% of the care partners, nurses, and other life enrichment staff who worked in the care area attended the workshop (8 Life care enrichment staff, 3 nurses, and 11 care partners, respectively). The didactic, interactive presentation included hands on practice with Montessori materials. A team was then created to lead the Montessori initiative within the community. This team, in collaboration with the first author, identified barriers to participation and needed environmental cues to support the Montessori activities. The following environmental changes were made: replaced room name and number plate room signs with photos that were enlarged, enhanced with a colorful border, framed, and hung on the wall next to the elder’s bedroom doorway; furniture was rearranged to increase resident activity participation; wayfinding signage and cues were created; wayfinding cues (large colorful themed decals) were placed at the entrance to elder bedroom hallways and new signage was designed and mounted to improve the elders’ ability to find common locations such as their rooms, the dining room and the living room.  Kelly green name tags were implemented for all employees and elders within the community. Name tags were of appropriate type size and font for elders to call both each other and other care partners by name throughout the living community.
Next, all elders’ interests, skills and abilities were documented through a “Life Story Form” which was co-constructed by assisted living employees and the 1st author (Appendix A). After reviewing these forms, 84 different types of activity materials were purchased or created by the authors, with approximately 25 displayed at one time on trays or in containers and placed in the living room bookcases. Signs were created for some of the activities to act as invitations for engagement.  Activities were based on elders’ interests and some examples included flower arranging, sewing, reading, games, sorting, folding laundry, or puzzles. A refreshment station was created to promote the independent consumption of food and drink throughout the day.
In addition, elders’ interests and desires were identified to match each elder with a community role to support purposeful and meaningful living. Prior to the implementation of the program, none of the elders had a community role. Possible community roles included wiping down tables and chairs after meals, garden caretaker, delivering cards, setting tables, passing out waters, serving appetizers, folding bulletins, visiting other residents, writing the menu for lunch and supper, playing the piano for sing a longs and bible study, delivering mail, volunteering in the mini mart volunteer, creating art with a fellow resident. Families and staff were also instructed, via a workshop on making memory books, to support both conversation and activities of daily living.
Weekly coaching calls that ranged in time from 30 minutes to 120 minutes were conducted with the first author and the Life enrichment staff for a 1-year period.  These calls were designed to problem solve barriers to program implementation, as described below.

 

Results

Twenty-nine elders participated in the implementation of Montessori for Aging in Dementia had a mean age 89.52 years (SD = 7.17) The majority of participants were female (26/29) and wore glasses (22/29). Most of the participants did not wear hearing aids (23/29). All of the participants spoke English, and one participant was bilingual, also speaking German fluently. All participants passed a conversational screening (8), demonstrating ability to participate in conversation verbally at least at the word level. The majority of participants passed a reading screening (9) (20/29) at a 12-point font, (3/29) at a 16-point font, (2/29) at a 24-point font, and (1/29) at a 36-point font. Three participants did not pass the reading screening due to significant visual challenges; however, these participants were still included in the study as they participated in personalized roles and activities that did not require fine use of vision or visual cues. Participants’ Montreal Cognitive Assessment[10] mean scores were 9.86 out of 30 (SD = 5.71; range = 2 – 25). All employee participants were female, except for one male; 8 were Life care enrichment staff, 3 were nurses, and 11 were care partners.
The first goal of this evaluation was to demonstrate implementation of the MDA program by increasing the adoption of leadership, staff, and environmental features of the program. Table 1 illustrates the pre- and post-scores on the MDA Implementation checklist. Staff and elders were observed, policies and practices were reviewed and the environment was evaluated to determine the degree of implementation of each Montessori program standard. Each standard was rated on a Likert scale reflecting ‘0’ meaning no implementation and ‘4’ meaning fully implemented. Likert scale ratings were then converted to percentages to describe the degree to which the community was enacting the practice: ‘0’ or not at all implemented, 25% implemented; 50% implemented; 75% implemented or 100% or fully implemented.
Upon paired t-tests, significant differences for each aspect of the program (i.e., Leadership (p<.01), Staff (p<.002), and Environment) (p<.04) were demonstrated by comparing pre- and post- program implementation features. Although these data confirm that significant changes were made in all program areas, the implementation percentage scores ranged from 67% to 71% at the end of the study, documenting that the program was less than fully implemented.
The second goal of this program was to increase elder engagement in purposeful activities, improve sense of well-being, improve affect, reduce psychotropic medication use, hospitalizations and falls, and reduce occurrence of elder neuropsychiatric symptoms due to dementia, and thereby, improve perceived quality of life. The frequency of falls, medications, hospitalizations and neuropsychiatric symptoms due to dementia from nursing notes pre- and post-implementation are documented in Table 2. After frequency and then descriptive analysis, none of the paired sample t-test pre-post comparisons were significantly different.  In addition, there were no statistically significant pre-post paired sample t-test differences between the means of the frequency and/or intensity of agitated events as rated by the employees for the elder participants in the study on the Cohen-Mansfield Agitation Inventory (2).

Table 2
Pre- and Post-Implementation frequency of neuropsychiatric symptoms due to dementia, falls, hospitalizations, and medications, Cohen-Mansfield Agitation Inventory

Note:  None of the pre-post comparisons were significantly different.

 

Descriptive analysis of the Observation Measure of Engagement (3) which included subscales of Attention and Attitude, included mean, standard deviation and range of variables. Paired sample T-test comparisons did not reveal any significant changes pre- and post-program implementation. Descriptive analysis of means via a paired sample t-test on the Observed Emotion Rating Scale (4), however, revealed a significant increase in positive emotions from pre-implementation, (M=3.35, SD =1.04) to post-implementation (M=3.97, SD=.76); t(28)=-2.83, p = .009.  Table 3 displays the means pre- and post-program implementation for the observational measures of engagement and affect.  Reliability for each point of observation on these two measures was completed by two independent observers and point-to-point agreement was 80% or greater, with a range of 80% to 100% agreement.  In addition, 15 out of 29 elders had a purposeful community role post program implementation.

Table 3
Pre- and Post-Implementation scores on the Observed Measure of Engagement3 and the Observed Emotion Affect Scale4

Note:  * p<.01

 

The Dementia Quality of Life Scale (5) captured significant positive outcomes from pre-program implementation to post-program implementation in the areas of self-esteem, positive affect and belonging. These mean data are further displayed in Table 4 and results of paired t-tests reveal the following significant differences for self-esteem, positive affect, and belonging respectively, t(28)=-4.21, p = .000; t(28)=-2.45, p=.017; t(28)=-5.03, p=.000. Significant changes were not, however, noted in negative affect or aesthetics.

Table 4
Pre- and post-implementation scores on the Dementia quality of life scale5

Note:  * p<.01; **p<.001

 

Descriptive analysis of the job satisfaction survey in terms of means, standard deviations and range of responses was also conducted. Staff displayed statistically significantly higher job satisfaction (6) from pre-implementation (M=1.56, SD =.32) to post-implementation (M=2.04, SD=.5); t(20)=-3.4, p = .003 according to paired sample t-tests.

 

Discussion

The purpose of this study was to evaluate the implementation of the MDA program in an assisted living facility and document elders’ and staff outcomes.  After 1 year, the community had adopted 68% of program features compared to 28% at study start. This represents statistically significant improvements in each area of the AMI MDA program, Leadership, Staff, and Environment.   One very critical barrier to implementation was the lack of a large, cohesive, multidisciplinary team to lead and sustain this initiative.  During the project, the community experienced higher than typical staff turnover for their community, which resulted in lower than normal staffing levels.  Nursing management worked overtime as caregivers to meet the basic needs of the elders. This meant that nursing management and front-line nursing staff were not available for the Montessori team meetings.  In addition, there was turnover in the Life Enrichment department, so this department also operated with less than normal staffing for several months.  A new Life Enrichment assistant needed to be trained in the middle of the project.  The dietary department was also negatively affected by turnover, which made it difficult to collaborate with this department and incorporate aspects of the Montessori program at meal times.  These staffing challenges made it problematic to both implement and sustain the Montessori program because staff were focused on addressing the immediate care issues of the elders; there was limited time for helping the elders to learn how to engage in new and different types of activities.  As a result, the bulk of the program responsibilities were managed by the Life Enrichment Specialist and the Director of Dementia Care Services.
It should be noted that in comparison to other communities that have implemented a Montessori-based approach11, this project measured the program features implemented via a fidelity measure, the MDA Implementation Checklist.  It is important for future programs to document the fidelity of their implementation in order to be able to compare across studies and to better understand the relative importance of specific program features.
With the documented level of implementation at 68%, elders in this study responded to the changes implemented by displaying significantly more positive emotions, affect, and feelings of self-esteem and belonging after the intervention.  These quality of life improvements may be related to a variety of changes made to the environment, the increase in activities and roles, and the behaviors of the staff as a result of their training. Future studies will need to evaluate the relative importance of these different feature changes; the current study was not designed to do a components/feature analysis.  Although positive trends were documented for increased engagement, the fact that the program was not fully implemented may explain the lack of significant differences in engagement by elders. The fact that only 15 of the 29 elders were engaged in a community role at the end of the project suggests that additional staff training may be necessary to support these roles.
It is important to note that there were no statistically significant changes in the variables that have been reported to change in other Montessori programs (11).  Desired reductions in medication use, falls, hospitalizations, and neuropsychiatric symptoms due to dementia were not documented, possibly due to the fact that the frequency of these instances was relatively low, with the exception of medications, at the start of the study.  An additional rationale for this result may include the lack of statistical power due to decreased sample size.
Overall, employee job satisfaction was higher after the implementation of the program; the staff who participated in the training and witnessed changes in the elders reported a greater degree of job satisfaction.  The persistent challenges of short-staffing and staff turnover may have interfered with staff fully implementing the program and thereby not experiencing the potential benefits of the program.

 

Conclusions

Overall this study documents the value of a person-centered, Montessori-based approach to the care of elders with dementia and other conditions of aging.  Implementation of specific leadership, staff, and environmental features leads to changes in the quality of life and affect of individuals with dementia and in the job satisfaction of the staff employed to care for them. Future documentation of the full implementation of this MDA approach has the potential to change significantly the culture of care and quality of life outcomes of persons with dementia.

 

Funding sources: This work was supported by the State of Michigan Health Endowment Fund and Blue Cross Blue Shield of Michigan Foundation.  The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.

Conflict of Interest: Ms. Brush reports personal fees from Clark Retirement Community during the conduct of the study; personal fees as Owner, Brush Development, outside the submitted work; and serves as a volunteer member of the Association Montessori International Advisory Board for Montessori for Dementia and Aging. Dr. Douglas reports personal fees from Brush Development, during the conduct of the study. Dr. Bourgeois reports personal fees from Brush Development Company during the conduct of the study; and serves as a volunteer member of the Association Montessori International Advisory Board for Montessori for Dementia and Aging.

Ethical Standard: The Institutional Review Board of Ideas Institute approved all study procedures and consent forms. An introductory letter and consent form was sent to the person holding durable power of attorney for each elder in the community.  A simplified assessment to participate was given to all elder participants.  No baseline data was taken until after receipt both of the signed power of attorney consent form and signed participant assent. Both documents were kept by the lead researcher in a secure location.

 

References

1.    Association Montessori Internationale.  Advisory Group Charter, Quality Areas, Standards and Indicators. Amsterdam, Netherlands: Author, 2015
2.    Cohen-Mansfield, J., Marx, M., & Rosenthal, A. A description of agitation in a nursing home. Journals of Gerontology, 1989;44(3), M77-M84.
3.    Cohen-Mansfield, Ph.D., J. Maha Dakheel-Ali, M., &  Marx, M.S. Engagement in persons with dementia: the concept and its measurement.  Am J Geriatr Psychiatry. 2009; Apr; 17(4): 299–307.
4.    Lawton, M.P., Van Haitsma, K.S., & Klapper, J.A.  Observed Affect in Nursing Home Residents.  Journals of Gerontology B: Psychological Sciences, 1996;51:1, 3-14.
5.    Brod, M, Stewart, A.L., Sands, L., & Walton, P. Conceptualization and Measurement of Quality of Life in Dementia: The Dementia Quality of Life Instrument (DQoL) The Cerontologist, 1999; Vol. 39, No. 1, 25-35.
6.    Kiefer, K, Harris-Kojetin, L. Brannon, D, Barry, T., Vasey, J.& Lepore, J. Measuring LONG-TERM CARE WORK:A Guide to Selected Instruments to Examine Direct Care Worker Experiences and Outcomes. US Department of Health & Human Services, Office of the Assistant Secretary for Planning & Evaluation, US Department of Labor, Office of the Assistant Secretary for Policy, 2005, Appendix 3, page 60S.
7.    Camp, C. J., Bourgeois, M. S., & Erkes, J. Person-centered care. In G. Smith (Ed.) APA Handbook of Dementia (pp. 615-629). American Psychological Association: Washington, D.C, 2018.
8.    Bourgeois, M., Dijkstra, K., Burgio, L., & Allen-Burge, R. Memory aids as an AAC strategy for nursing home residents with dementia.  Augmentative and Alternative Communication, 2001;17, 196-210.
9.    Benigas, J., Brush, J. & Elliot, G. Reading Screening in Spaced Retrieval Step by Step.  Baltimore, MD: Heath Professions Press, pages 2016;40-41.
10.    Nasreddine ZS1, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for for mild cognitive impairment. J Am Geriatr Soc. 2005; 53:695-699
11.    Bourgeois, M., Brush, J., Elliot, G., & Kelly, A. Join the Revolution:  How Montessori for Aging and Dementia can change long-term care culture. Seminars in Speech & Language, 2015;36(3), 209-214

IMPLEMENTATION OF THE MONTESSORI PROGRAM IN ASSISTED LIVING: POSITIVE OUTCOMES AND CHALLENGES

 

J. Brush1, N. Douglas2, M. Bourgeois3

 

1. Brush Development, Chardon, OH, USA; 2. Central Michigan University, Mount Pleasant, MI, USA; 3. University of South Florida, Tampa, FL, USA.  Corresponding author: Jennifer Brush, Brush Development, 9935 Campton Ridge Drive, Chardon, OH 44024, jennifer@BrushDevelopment.com, 440-289-0037

 

Jour Nursing Home Res 2018;4:42-48
Published online October 18, 2018, http://dx.doi.org/10.14283/jnhrs.2018.8

 


Abstract

The purpose of this study was to evaluate the impact of the implementation of the Association Montessori Internationale (AMI) Montessori for Dementia and Aging (1) (MDA) program in a memory care Assisted Living community. A pre-post quasi experimental descriptive study was conducted with 29 elders in an assisted living community. The AMI MDA program1 was implemented over the course of one year; adoption of program features was documented pre- and post-implementation. Outcomes for elders included number of neuropsychiatric symptoms due to dementia (Cohen-Mansfield Agitation Inventory (2)), falls, medications and hospitalizations; attitude, attention and engagement (Observational Measure of Engagement (3)), affect (Observed Emotion Rating Scale (4)); and the Dementia Quality of Life Scale (5). The Benjamin Rose Nurse Assistant Job Satisfaction Scale (6) was used to measure employee job satisfaction before and after implementation of the program. After 1 year, the community had adopted 68% of program features compared to 28% at study start. Elders displayed significantly more positive emotions, affect, and feelings of self-esteem and belonging after the intervention; positive trends were documented for increased engagement. Overall, employee job satisfaction was higher after the implementation of the program; barriers to full implementation, however, were identified.

Key words: Montessori, aging, dementia, assisted living.


 

Introduction

A new person-centered approach for long-term care and aging in place communities, AMI Montessori for Dementia and Aging (1) extends the tenets of person-centered care by focusing on the abilities, needs, interests, and strengths of persons with dementia. This innovative team approach creates worthwhile and meaningful roles, routines, and activities for the person within a supportive physical environment. Montessori’s philosophy was to enable persons to be as independent as possible, to have a meaningful place in their community, to possess high self-esteem, and to have the chance to make meaningful contributions to their community. The purpose of this study was to evaluate the impact of the implementation of the AMI MDA (1) program on elder and staff outcomes in a memory care Assisted Living community. The AMI MDA program was created based on the pedagogical philosophy of Dr. Maria Montessori and evidenced based person-centered approaches (7) to dementia care.  The merging of the two disciplines results in a person-centered approach to life that addresses the cognitive, physical, spiritual, social and emotional needs of elders and those living with dementia. This approach facilitates changes to the way one interrelates with elders and people with dementia by improving the quality of interactions.  The goal of the program was to form and maintain a caring community that is aligned with elders’ needs, interests, and abilities by creating an environment that is carefully prepared to provide opportunities for success, choice, enhanced independence and self-initiated activity. Elders’ lives are therefore enriched through the engagement in roles, routines and activities, fostering a sense of community belonging and well-being.
The AMI Montessori for Dementia and Aging Advisory Board has established standards and quality indicators for the application of Montessori in an aged care setting (1).  The standards address three critical areas of program implementation: leadership; staff; and the prepared environment.  In a community that has fully implemented this philosophy, the organizsation’s leadership encourages elders to be actively involved in the decision making related to daily life.  Multi-disciplinary teams are created, with a commitment to working together, with the purpose of meeting the needs of each person in their care.  In addition, the organization’s leadership uses effective communication tools to give staff, families, and elders a full understanding about the Montessori approach. There are financial commitments to budget allocations for best practice resources and staff training is conducted by a certified AMI Montessori for Dementia and Aging Educator. There is a formal commitment to continuous improvement of the implementation of MDA.  For instance, staff collect, maintain and use a comprehensive individual profile of needs, interests and strengths. Through collaboration with elders and their families, staff actively seek out and create opportunities for elders to act independently, exercise choice, move about with freedom and engage in activities of interest. Throughout the day, observation is utilized as a key tool for reflection and identification of individual needs. The environment must be visually organized and aesthetically pleasing. Shared spaces in the care community must provide enticement to engage by having dedicated, interactive areas allocated for activities. A Montessori community has evidenced-based cues and modifications in the environment to support independence. The environment should offer a full complement of appropriate multisensory materials, resources and activities that are accessible at any time.

Study Purpose

The purpose of this project was to implement and evaluate the AMI MDA program in a memory care Assisted Living community.  The program had the following goals:
1. Demonstrate implementation of the MDA program by increasing the adoption of environmental, staff, and leadership features of the program.
2. Increase elder engagement in purposeful activities, improve sense of well-being, improve affect, reduce psychotropic medication use, hospitalizations and falls, and reduce occurrence of neuropsychiatric symptoms due to dementia.
3. Increase staff job satisfaction.

 

Methods

The Institutional Review Board of Ideas Institute approved all study procedures and consent forms. This study utilized a pre-post, quasi-experimental design to implement and evaluate outcomes of the MDA program in one Midwestern assisted living in the United States. The assisted living is part of a non-profit continuing care retirement community housed on two campuses that includes independent and assisted living as well as skilled nursing.  The assisted living area contains 42 private bedrooms and shared activity, dining and living room spaces.

Participants

Study participants were (1) 29 elders with dementia or other cognitive impairment who resided in the community and (2) 22 employees of the assisted living community. An introductory letter and consent form was sent to the person holding durable power of attorney for each elder in the community.  After receipt of the signed consent form, the authors reviewed the elder’s medical chart; completed a communication, cognitive and reading screening of the elder; conducted an observation during their daily activities; and completed the quality of life assessment. Participants who were employees of the assisted living community provided informed consent to complete the following: 1) a job satisfaction survey (6); and 2) a rating of the elder’s neuropsychiatric symptoms (2) throughout the course of 2-weeks.

Measures

Measures used to collect data from participants who were elders with dementia or other cognitive impairment included: 1) chart review confirming diagnosis of dementia or other cognitive impairment; frequency of hospitalizations, falls, neuropsychiatric symptoms due to dementia and medications per nursing notes in the six months before and 3 months after implementation of the program; 2) informal communication screening (8)) and reading screening (9)) ; 3) the Montréal Cognitive Assessment  (MoCA) (10); 4) the Observational Measure of Engagement (3); 5) the Observed Emotion Rating Scale (4)); and, 6) the Dementia Quality of Life Scale (5). Employee participants completed the Benjamin Rose Nurse Satisfaction Survey (6), and the Cohen-Mansfield Agitation Inventory (2) for elder participants in the study. Lastly, a program implementation checklist adapted from AMI MDA standards (Table 1) was also completed to assess program fidelity and measure specific elements of program implementation. All of these measures with the exception of the informal communication screening, reading screening and MoCA were re-administered post- implementation and are described in more detail below.

Table 1
Montessori for Aging and Dementia Program Implementation Checklist

 

After informed consent was completed, the second author reviewed each participant’s medical record to confirm diagnosis of cognitive impairment or dementia related disorder. The number of current medications, falls and hospitalizations was also recorded in the prior 6 months pre-implementation (6-months prior to implementation month 1) and at 3- months post-implementation. Finally, nursing notes were reviewed by the second author to assess frequency of neuropsychiatric symptoms due to dementia in the prior 6 months pre-implementation (6-months prior to implementation month 1) and at 3-months post-implementation. Neuropsychiatric symptoms due to dementia were defined as events that were significant enough for the nursing staff to record in a log and included violence toward other elders, inappropriate sexual advances toward other elders and verbal lashing out toward care partners.
The informal communication screening (8) was administered to each elder as well. The participant was asked his or her age, primary language, and they were observed as to whether or not they had glasses and/or hearing aids. During this process, elders were asked to about their education, hobbies, former occupation, likes and dislikes. The researchers observed conversational features of the elder including the ability to maintain topic, to initiate new topics, to request clarification, to take turns and ask questions. Researchers also noted if the elder was verbal at the single word, short phrase, few sentences or many sentences level. A reading screening was then conducted with each elder (9). Elders were assessed according to the optimal font for oral reading and reading for following simple, 1-step directions.
The MoCA (10) was completed with each elder for descriptive purposes only. The MoCA is a well-studied cognitive screener assessing visuospatial and executive functioning, naming, memory, attention, language, abstraction, delayed recall and orientation. Normal cognitive functioning is considered to be a score of 26 or higher out of 30 possible points, adding an additional point for any individuals who have 12 years of education or less.

The Observational Measure of Engagement (3) involved the investigators rating each elder according to ‘Attention’ and ‘Attitude’ during a 5-minute observation of the elder during an activity. Attention was rated on a 4 point Likert scale where 1 corresponds to ‘not attentive’ and 4 corresponds to ‘very attentive’. Attitude was ranked on a 7 point Likert scale, ranging from 1 (very negative) to 7 (very positive). Inter-rater reliability for this measure was reported to be 84% for engagement outcome measures (3).
The Observed Emotion Rating Scale (4) was completed for each elder as well. The investigators ranked elders according to their facial affect and other qualities that display either negative emotions or positive emotions. The maximum score for the display of both positive and negative emotions is 5, corresponding to the idea that the participant strongly displays that emotion. The minimum score for the display of both positive and negative emotions is 1, corresponding to the idea that the participant never displays that emotion. Kappa reliability for each of these emotion ratings was reported to be .76 or higher and validity, and validity estimates were also deemed supportive of the measure.
The Dementia Quality of Life Scale (5) is a self-report measure of 5-constructs of quality of life: positive affect, negative affect, feelings of self-esteem, feelings of belonging, and experience of aesthetics. Visual supports, including a 24-point type size rating scale and captioned pictures representing the topic of the questions, were used to support communication during the administration of this measure. Internal consistency of all constructs was reported to be .67 or higher
The Benjamin Rose Nurse Assistant Job Satisfaction Scale (6) was administered as a measure of job satisfaction before and after implementation of the program. A score of 0 reflects a highly dissatisfied employee and a score of 3 reflects a highly satisfied employee. This measure has been shown to demonstrate appropriate validity and reliability of .92 (6).
The Cohen-Mansfield Agitation Inventory (2) was completed by employee participants for all participants at pre-and post-implementation of the program. Familiar staff rated levels of agitation for 29 types of physical and verbal aggressive and non-aggressive behavior. While there are subscales to this measure, for the purposes of this study, participants were given an overall agitation score, ranging from 150 (maximum agitation) to 29 (minimum agitation). Cronbach’s alpha for this measure was reported to be .86, .91 and .87 for raters (2).
A Program Implementation Checklist adapted from the AMI MDA standards was developed to record the frequency of the program features/standards in place before and after the program was implemented.  As shown in Table 1, three standards areas were assessed: Leadership (7 features), Staff (9 features) and Prepared Environment (6 features), for a total of 88 required components of a fully implemented program. Each feature was observed to be:  0=Not at all implemented; 1=started to be implemented; 2=moderately implemented; 3=mostly implemented; 4=fully implemented.

Data Analysis

All raw data was entered into Microsoft Excel and later SPSS 24. Descriptive data analysis of all variables included means, standard deviations and ranges of responses. Pre-post and paired sample t-test comparisons were conducted as appropriate.

Implementation of Montessori Program Procedures

After obtaining consent for the elder participants, and collecting the pre-implementation measures the project began with a two-day educational workshop by the first author; 80% of the care partners, nurses, and other life enrichment staff who worked in the care area attended the workshop (8 Life care enrichment staff, 3 nurses, and 11 care partners, respectively). The didactic, interactive presentation included hands on practice with Montessori materials. A team was then created to lead the Montessori initiative within the community. This team, in collaboration with the first author, identified barriers to participation and needed environmental cues to support the Montessori activities. The following environmental changes were made: replaced room name and number plate room signs with photos that were enlarged, enhanced with a colorful border, framed, and hung on the wall next to the elder’s bedroom doorway; furniture was rearranged to increase resident activity participation; wayfinding signage and cues were created; wayfinding cues (large colorful themed decals) were placed at the entrance to elder bedroom hallways and new signage was designed and mounted to improve the elders’ ability to find common locations such as their rooms, the dining room and the living room.  Kelly green name tags were implemented for all employees and elders within the community. Name tags were of appropriate type size and font for elders to call both each other and other care partners by name throughout the living community.
Next, all elders’ interests, skills and abilities were documented through a “Life Story Form” which was co-constructed by assisted living employees and the 1st author (Appendix A). After reviewing these forms, 84 different types of activity materials were purchased or created by the authors, with approximately 25 displayed at one time on trays or in containers and placed in the living room bookcases. Signs were created for some of the activities to act as invitations for engagement.  Activities were based on elders’ interests and some examples included flower arranging, sewing, reading, games, sorting, folding laundry, or puzzles. A refreshment station was created to promote the independent consumption of food and drink throughout the day.
In addition, elders’ interests and desires were identified to match each elder with a community role to support purposeful and meaningful living. Prior to the implementation of the program, none of the elders had a community role. Possible community roles included wiping down tables and chairs after meals, garden caretaker, delivering cards, setting tables, passing out waters, serving appetizers, folding bulletins, visiting other residents, writing the menu for lunch and supper, playing the piano for sing a longs and bible study, delivering mail, volunteering in the mini mart volunteer, creating art with a fellow resident. Families and staff were also instructed, via a workshop on making memory books, to support both conversation and activities of daily living.
Weekly coaching calls that ranged in time from 30 minutes to 120 minutes were conducted with the first author and the Life enrichment staff for a 1-year period.  These calls were designed to problem solve barriers to program implementation, as described below.

 

Results

Twenty-nine elders participated in the implementation of Montessori for Aging in Dementia had a mean age 89.52 years (SD = 7.17) The majority of participants were female (26/29) and wore glasses (22/29). Most of the participants did not wear hearing aids (23/29). All of the participants spoke English, and one participant was bilingual, also speaking German fluently. All participants passed a conversational screening (8), demonstrating ability to participate in conversation verbally at least at the word level. The majority of participants passed a reading screening (9) (20/29) at a 12-point font, (3/29) at a 16-point font, (2/29) at a 24-point font, and (1/29) at a 36-point font. Three participants did not pass the reading screening due to significant visual challenges; however, these participants were still included in the study as they participated in personalized roles and activities that did not require fine use of vision or visual cues. Participants’ Montreal Cognitive Assessment (10) mean scores were 9.86 out of 30 (SD = 5.71; range = 2 – 25). All employee participants were female, except for one male; 8 were Life care enrichment staff, 3 were nurses, and 11 were care partners.
The first goal of this evaluation was to demonstrate implementation of the MDA program by increasing the adoption of leadership, staff, and environmental features of the program. Table 1 illustrates the pre- and post-scores on the MDA Implementation checklist. Staff and elders were observed, policies and practices were reviewed and the environment was evaluated to determine the degree of implementation of each Montessori program standard. Each standard was rated on a Likert scale reflecting ‘0’ meaning no implementation and ‘4’ meaning fully implemented. Likert scale ratings were then converted to percentages to describe the degree to which the community was enacting the practice: ‘0’ or not at all implemented, 25% implemented; 50% implemented; 75% implemented or 100% or fully implemented.
Upon paired t-tests, significant differences for each aspect of the program (i.e., Leadership (p<.01), Staff (p<.002), and Environment) (p<.04) were demonstrated by comparing pre- and post- program implementation features. Although these data confirm that significant changes were made in all program areas, the implementation percentage scores ranged from 67% to 71% at the end of the study, documenting that the program was less than fully implemented.
The second goal of this program was to increase elder engagement in purposeful activities, improve sense of well-being, improve affect, reduce psychotropic medication use, hospitalizations and falls, and reduce occurrence of elder neuropsychiatric symptoms due to dementia, and thereby, improve perceived quality of life. The frequency of falls, medications, hospitalizations and neuropsychiatric symptoms due to dementia from nursing notes pre- and post-implementation are documented in Table 2. After frequency and then descriptive analysis, none of the paired sample t-test pre-post comparisons were significantly different.  In addition, there were no statistically significant pre-post paired sample t-test differences between the means of the frequency and/or intensity of agitated events as rated by the employees for the elder participants in the study on the Cohen-Mansfield Agitation Inventory (2).

Table 2
Pre- and Post-Implementation frequency of neuropsychiatric symptoms due to dementia, falls, hospitalizations, and medications, Cohen-Mansfield Agitation Inventory

Note:  None of the pre-post comparisons were significantly different.

 

Descriptive analysis of the Observation Measure of Engagement (3) which included subscales of Attention and Attitude, included mean, standard deviation and range of variables. Paired sample T-test comparisons did not reveal any significant changes pre- and post-program implementation. Descriptive analysis of means via a paired sample t-test on the Observed Emotion Rating Scale (4), however, revealed a significant increase in positive emotions from pre-implementation, (M=3.35, SD =1.04) to post-implementation (M=3.97, SD=.76); t(28)=-2.83, p = .009.  Table 3 displays the means pre- and post-program implementation for the observational measures of engagement and affect.  Reliability for each point of observation on these two measures was completed by two independent observers and point-to-point agreement was 80% or greater, with a range of 80% to 100% agreement.  In addition, 15 out of 29 elders had a purposeful community role post program implementation.

Table 3
Pre- and Post-Implementation scores on the Observed Measure of Engagement3 and the Observed Emotion Affect Scale4

Note:  * p<.01

 

The Dementia Quality of Life Scale (5) captured significant positive outcomes from pre-program implementation to post-program implementation in the areas of self-esteem, positive affect and belonging. These mean data are further displayed in Table 4 and results of paired t-tests reveal the following significant differences for self-esteem, positive affect, and belonging respectively, t(28)=-4.21, p = .000; t(28)=-2.45, p=.017; t(28)=-5.03, p=.000. Significant changes were not, however, noted in negative affect or aesthetics.
Descriptive analysis of the job satisfaction survey in terms of means, standard deviations and range of responses was also conducted. Staff displayed statistically significantly higher job satisfaction (6) from pre-implementation (M=1.56, SD =.32) to post-implementation (M=2.04, SD=.5); t(20)=-3.4, p = .003 according to paired sample t-tests.

Table 4
Pre- and post-implementation scores on the Dementia quality of life scale5

Note:  * p<.01; **p<.001

 

Discussion

The purpose of this study was to evaluate the implementation of the MDA program in an assisted living facility and document elders’ and staff outcomes.  After 1 year, the community had adopted 68% of program features compared to 28% at study start. This represents statistically significant improvements in each area of the AMI MDA program, Leadership, Staff, and Environment.   One very critical barrier to implementation was the lack of a large, cohesive, multidisciplinary team to lead and sustain this initiative.  During the project, the community experienced higher than typical staff turnover for their community, which resulted in lower than normal staffing levels.  Nursing management worked overtime as caregivers to meet the basic needs of the elders. This meant that nursing management and front-line nursing staff were not available for the Montessori team meetings.  In addition, there was turnover in the Life Enrichment department, so this department also operated with less than normal staffing for several months.  A new Life Enrichment assistant needed to be trained in the middle of the project.  The dietary department was also negatively affected by turnover, which made it difficult to collaborate with this department and incorporate aspects of the Montessori program at meal times.  These staffing challenges made it problematic to both implement and sustain the Montessori program because staff were focused on addressing the immediate care issues of the elders; there was limited time for helping the elders to learn how to engage in new and different types of activities.  As a result, the bulk of the program responsibilities were managed by the Life Enrichment Specialist and the Director of Dementia Care Services.
It should be noted that in comparison to other communities that have implemented a Montessori-based approach11, this project measured the program features implemented via a fidelity measure, the MDA Implementation Checklist.  It is important for future programs to document the fidelity of their implementation in order to be able to compare across studies and to better understand the relative importance of specific program features.
With the documented level of implementation at 68%, elders in this study responded to the changes implemented by displaying significantly more positive emotions, affect, and feelings of self-esteem and belonging after the intervention.  These quality of life improvements may be related to a variety of changes made to the environment, the increase in activities and roles, and the behaviors of the staff as a result of their training. Future studies will need to evaluate the relative importance of these different feature changes; the current study was not designed to do a components/feature analysis.  Although positive trends were documented for increased engagement, the fact that the program was not fully implemented may explain the lack of significant differences in engagement by elders. The fact that only 15 of the 29 elders were engaged in a community role at the end of the project suggests that additional staff training may be necessary to support these roles.
It is important to note that there were no statistically significant changes in the variables that have been reported to change in other Montessori programs (11).  Desired reductions in medication use, falls, hospitalizations, and neuropsychiatric symptoms due to dementia were not documented, possibly due to the fact that the frequency of these instances was relatively low, with the exception of medications, at the start of the study.  An additional rationale for this result may include the lack of statistical power due to decreased sample size.
Overall, employee job satisfaction was higher after the implementation of the program; the staff who participated in the training and witnessed changes in the elders reported a greater degree of job satisfaction.  The persistent challenges of short-staffing and staff turnover may have interfered with staff fully implementing the program and thereby not experiencing the potential benefits of the program.

 

Conclusions

Overall this study documents the value of a person-centered, Montessori-based approach to the care of elders with dementia and other conditions of aging.  Implementation of specific leadership, staff, and environmental features leads to changes in the quality of life and affect of individuals with dementia and in the job satisfaction of the staff employed to care for them. Future documentation of the full implementation of this MDA approach has the potential to change significantly the culture of care and quality of life outcomes of persons with dementia.

 

Funding sources: This work was supported by the State of Michigan Health Endowment Fund and Blue Cross Blue Shield of Michigan Foundation.  The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.

Conflict of Interest: Ms. Brush reports personal fees from Clark Retirement Community during the conduct of the study; personal fees as Owner, Brush Development, outside the submitted work; and serves as a volunteer member of the Association Montessori International Advisory Board for Montessori for Dementia and Aging. Dr. Douglas reports personal fees from Brush Development, during the conduct of the study. Dr. Bourgeois reports personal fees from Brush Development Company during the conduct of the study; and serves as a volunteer member of the Association Montessori International Advisory Board for Montessori for Dementia and Aging.

Ethical Standard: The Institutional Review Board of Ideas Institute approved all study procedures and consent forms. An introductory letter and consent form was sent to the person holding durable power of attorney for each elder in the community.  A simplified assessment to participate was given to all elder participants.  No baseline data was taken until after receipt both of the signed power of attorney consent form and signed participant assent. Both documents were kept by the lead researcher in a secure location.

 

References

1.    Association Montessori Internationale.  Advisory Group Charter, Quality Areas, Standards and Indicators. Amsterdam, Netherlands: Author, 2015
2.    Cohen-Mansfield, J., Marx, M., & Rosenthal, A. A description of agitation in a nursing home. Journals of Gerontology, 1989;44(3), M77-M84.
3.    Cohen-Mansfield, Ph.D., J. Maha Dakheel-Ali, M., &  Marx, M.S. Engagement in persons with dementia: the concept and its measurement.  Am J Geriatr Psychiatry. 2009; Apr; 17(4): 299–307.
4.    Lawton, M.P., Van Haitsma, K.S., & Klapper, J.A.  Observed Affect in Nursing Home Residents.  Journals of Gerontology B: Psychological Sciences, 1996;51:1, 3-14.
5.    Brod, M, Stewart, A.L., Sands, L., & Walton, P. Conceptualization and Measurement of Quality of Life in Dementia: The Dementia Quality of Life Instrument (DQoL) The Cerontologist, 1999; Vol. 39, No. 1, 25-35.
6.    Kiefer, K, Harris-Kojetin, L. Brannon, D, Barry, T., Vasey, J.& Lepore, J. Measuring LONG-TERM CARE WORK:A Guide to Selected Instruments to Examine Direct Care Worker Experiences and Outcomes. US Department of Health & Human Services, Office of the Assistant Secretary for Planning & Evaluation, US Department of Labor, Office of the Assistant Secretary for Policy, 2005, Appendix 3, page 60S.
7.    Camp, C. J., Bourgeois, M. S., & Erkes, J. Person-centered care. In G. Smith (Ed.) APA Handbook of Dementia (pp. 615-629). American Psychological Association: Washington, D.C, 2018.
8.    Bourgeois, M., Dijkstra, K., Burgio, L., & Allen-Burge, R. Memory aids as an AAC strategy for nursing home residents with dementia.  Augmentative and Alternative Communication, 2001;17, 196-210.
9.    Benigas, J., Brush, J. & Elliot, G. Reading Screening in Spaced Retrieval Step by Step.  Baltimore, MD: Heath Professions Press, pages 2016;40-41.
10.    Nasreddine ZS1, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for for mild cognitive impairment. J Am Geriatr Soc. 2005; 53:695-699
11.    Bourgeois, M., Brush, J., Elliot, G., & Kelly, A. Join the Revolution:  How Montessori for Aging and Dementia can change long-term care culture. Seminars in Speech & Language, 2015;36(3), 209-214

THE CAPACITY OF FOOD SERVICE PROVIDERS AS NUTRITION CHANGE AGENTS IN NURSING HOMES

 

L. Matwiejczyk, O. Farrer, J. Hamilton, M. Miller

 

College Nursing and Health Sciences, Flinders University, South Australia, Australia. Corresponding author:Louisa Matwiejczyk BA (Hons) Dip. Nut & Diet, Adv APD, Lecturer, Nutrition & Dietetics, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia 5001. Tel: +61872218848 Email: louisa.matwiejczyk@flinders.edu.au

Jour Nursing Home Res 2018;4:20-26
Published online May 9, 2018, http://dx.doi.org/10.14283/jnhrs.2018.5

 


Abstract

Background: Despite the correlation between the food provided and nursing home residents’ food satisfaction, Quality of Life and health, the capacity of food service providers to enact positive nutrition-related changes is unknown. Objectives: Researchers explored (1) the experiences and perceptions of senior-level food service providers from nursing homes (NH) to elicit change prompted by participation in a national educational intervention (2) the barriers and enablers to eliciting change and (3) practice implications. Design: Using qualitative methodology, individual semi-structured interviews were conducted four months after the intervention and thematically analyzed. Participants: Participants were 23 senior-level food service providers from 21 NH in Victoria, Australia. Results:  Participants started with the necessary confidence, knowledge and skills for food provision and three themes that best represent food service providers’ perceived capacity and experience to affect food service changes included: (1) participants’ motivations as change agents (2) empowerment facilitated by external factors (organizational, external and ongoing peer-support) and (3) constraints to enacting change (local and system-wide). Conclusion: Understanding the motivations and experiences of senior food service providers to enact change provides important information on the barriers and enablers which can be used to augment intervention planning and reduce the implementation gap between evidence-based recommendations and practice. A number of underlying mechanisms were identified and recommendations for system-wide changes made. Improvement in food and dining experiences may help to improve residents’ satisfaction with food which has been correlated with improved life satisfaction, health and well-being.

Key words: Aging, food services, long-term care, nursing homes, quality of life.


 

Introduction

Population ageing is a significant concern for many countries (1, 2). Life expectancy, low fertility rates and changing demographics have resulted in an unprecedented increase in people aged 65 years and over in the last five decades (2, 3).  Those aged 85 years and older are increasing at the fastest rate and expected to more than triple between 2015-2050 (2, 3). The United States, Japan, Australia and Europe will continue to have one of the longest life expectancies in the world and the ageing population is expected to present challenges to the welfare and health system (2).  An increasing number of older people are assessed as not being able to continue to reside independently in their own home and move into supported accommodation in long-term care facilities (4), termed Nursing Homes (NH).
Nutrition is vital for maintaining the health and well-being of residents in NH (1, 5, 6). Ageing alters nutritional requirements (1) and Protein-Energy Malnutrition, Vitamin D deficiency, Vitamin B deficiency and other micronutrients are challenges for residents in nursing homes (1). Crucial to residents’ quality of life (QOL) is also the enjoyment of food (7-11). Satisfaction with food is associated with increased mental well-being, social improvement and life satisfaction among older people (7-10) and is of particular relevance to residents (8, 11, 12).
Central to the provision of residents’ nutrition is the role and responsibilities of food service providers (13).  Residents are dependent upon the provision of their food from their carers, particularly food service staff. Where once many residents would have decided what and when they would eat, and what was ‘good’ for them, in NH these decisions are made predominately by food service staff (8, 11).  ‘Good food’ is important to residents and has been defined as food which is familiar, ‘home-style’, cooked with fresh ingredients and easily recognizable on the plate (11). ‘Good food’ symbolizes comfort for residents and as such is an important QOL indicator (11). Residents’ experience or perception of ‘good food’ in NH, however, is not always positive (11-13) and is an ongoing issue in NH (12).
Residents’ perceptions (11, 12, 14, 15) and NH carers’ experiences (6, 10, 14) have been explored, but despite the pivotal role of key food service staff their perspective remains unknown.  It is recommended that more successful interventions incorporate the views of the user to mitigate the implementation science gap translating best practice knowledge into day-to-day positive behaviours (16). An understanding from foodservice providers’ perspective would provide insights into the barriers and enablers experienced and the motivations to enact change. This would identify underlying mechanisms which may lead to positive behaviour changes, help inform the feasibility of food service staff initiated change and address a limited understanding of how interventions in NH work (17). This in turn may inform program-planners, policy makers and NH management with what would be needed to improve residents’ food satisfaction and QOL.
In response to the link between ‘good food’,  life satisfaction and the nutritional needs of the  population, a not-for-profit Foundation (Foundation) has delivered an education program with industry and nutrition experts for food service providers to transform the food experience of residents in NH (21). Novel to this program (also referred to as an intervention) is it is celebrity-led by a philanthropic cook and aims to empower key NH chefs and cooks from across the nation to become change agents in their local facilities.
The purpose of this study was to address an evidence gap by: (1) exploring  the experiences and perceptions of senior-level foodservice providers to elicit change in their facility following participation in an intervention developed to empower senior NH food service staff, (2) identifying barriers and enablers to enacting change and (3) identifying practice implications.

 

Method

Study Design and Setting

The intervention was a 14-hour interactive, discussion-based and predominately experiential program described elsewhere for senior level foodservice providers in NH. The program is underpinned by Social Cognitive Theory and adult learning theories which assumes participants’ start confident, are self-directed learners, learn best through doing and problem-solving and learning is enhanced by drawing on a repertoire of experiences and used immediately, Unique to this program is that it is celebrity-led with expert support with a focus on increasing the capacity of NH foodservice providers to be change agents.
Qualitative research was used as it lends itself to understanding the lived experience of those translating the gains from the educational intervention into real-life changes (19). The focus was on senior-level food service providers who had the mandate to enact change. Researchers undertook phone interviews using semi-structured questions four months after participants had attended a 14 hour educational program over three days in June 2015. Interviews were conducted four months later after a time considered long enough by participants to elicit change. Approval for the study was granted by the Social and Behavioral Research Ethics Committee at Flinders University South Australia.

Participant recruitment

Participants were recruited from the program which was promoted through aged care networks and restricted to facilities in Victoria, Australia (n=387). Facilities paid for flights and accommodation over the three days but the program itself is offered at no cost. At the program, participants were given a plain English summary of the study, had an opportunity to ask questions of the researchers and then provided signed consent.
All but one of the authors of this qualitative study have a wide range of experience working with older people in residential long-term care, community-based settings, food services and health services research. Prior to this study, the authors were unknown to the participants or their facilities.

Data collection

Semi-structured questions were asked using an interview schedule developed from the literature and trialed with potential users for usability. Topics related to food service providers’ perception of what changes they had made, what was their experience of making these changes, barriers and enablers and what additional support could assist. Questions were semi-structured to allow participants to relate their experience as they have perceived it and to allow themes in the analysis to emerge. All interviews were recorded and transcribed verbatim. All participants were interviewed. This was more than necessary for data saturation but this allowed for insights across a variety of facilities geographically and in size and purpose.

Data analysis

Transcribed data were analyzed using inductive thematic analysis where common themes were identified using a six-step process (19). The lead author (LM) and one other (JH) familiarized themselves with the data by listening to the recordings, reading the transcripts and taking notes. The transcripts were coded manually, line-by-line. Coding was carried out independently and the results discussed for common codes and quotations. Following coding, the quotations were sorted into groups to reflect the emerging themes. Different themes and sub-sets of themes were further identified during the write up of the analysis. Consensus was achieved in each of these steps. Trustworthiness of data was ensured through members checking what was reported against their experience. Quotes representative of the findings were selected for each theme and sub-theme for reporting purposes.

 

Results

Twenty-three senior-level foodservice providers from 21 NH participated in the phone interviews which were undertaken four months after the program and lasted between 16-55 minutes. Seven of the 30 program participants were not interviewed because two had left the position, two were on extended leave and three could not be contacted. Of the 23 participants interviewed, the majority had a senior food service role or managed the food services and there was a mixture of organisations from metropolitan areas, regional country towns and rural sites.  Foodservice type and the number of places per facility also varied, reflecting the diversity in NH. Selected characteristics of the participants and facilities are listed in Table 1.
When sharing their experience three main themes emerged: (1) participants’ motivations as change agents (2) empowerment facilitated by organizational, external and ongoing peer-support and (3)   constraints to enacting change.  Within these main themes were a number of inter-related sub-themes which could also be described as enablers or constraints.

 

Table 1
Selected characteristics of Nursing Homes in Victoria, Australia (n=21) and senior-level food service providers (n=23) interviewed for their experience and perception of enacting food service changes

 

Participants’ Motivations as Change Agents

All of the participants described changes to food service practices four months post-program including; food provided through menus and recipes, the dining environment and interactions with other staff, management involvement and residents’ satisfaction. Some participants described the experience as transformational and their responses indicated a high degree of conviction to make changes over the long term.
I said I will be continuing to lobby for more funds, more staff…. Yea for me, even my second chef said to me she really likes the new motivated me (Head Chef IP-3)
Participant’s motivations for acting as change agents varied and included wanting to make a difference, empathy for the residents and/or upholding standards.
I think that the food needs to be more important…. it needs to be pushed more and be more in the public eye and it needs to, you know, we just need to do better. (Head Chef IP-3)
Participants’ were empathetic towards residents and recognized that food was a significant source of pleasure, had meaning to residents, was a conduit for socializing and contributed to residents’ health as well as quality of life.
We have people here who …. the family don’t even come and visit. Which I think is incredibly sad and I sort of think food, for a lot of us, is a fairly major part so why can’t we make it the best that we can make it.  Why can’t we serve restaurant quality meals? Instead of just ‘ah well, it is only old people’. (Head Chef IP-3)
For some participants, making a difference was very personal with participants reflecting on their grandparents, parents, other family or friends as residents in NH. Of equal value for many participants was the motivation to provide food of an exemplar standard.
We are building four aged care facilities so it is really crucial for me to get the right mould to go forward because I really want to set a good standard and drive the innovation into the future. (Food Service Manager IP-5)
For many participants, residents’ feedback motivated them to continue with their change agenda following the program
You know when I have residents come and knock on the door and tell me what a lovely meal it was today and things like that it makes it all worthwhile. … (Head Chef IP-3)
Four months later all of the participants were still inspired to make changes to further improve recipes, menus, the dining environment and dining experience and collaborative, working relationships.
I want to have the reputation that people say ‘wow’ we want to go there when we get old because we hear the food is so good (Head Chef IP-3)

Empowerment Facilitated By External Influences

Organizational support

A number of common factors were attributed to building participants’ capacity to effect change. Management support was common to all participants and unconditional to a few participants following participation in the program.
Anything I’ve wanted to try I’ve been able to purchase …. anything.  They’ve went out and bought one of those fancy whippers and….All these new little contraptions that we’ve seen there, they’ve went and bought all of it. (Catering Manager IP-2)
Some participants described how they involved key management personnel such as the Chief Executive and Board members in food service decision-making by attending meetings with management, inviting management to eat with residents, and sharing meals with management for feedback.
The majority of the participants reported that many or most of the kitchen staff was supportive of change and gave examples of how they had empowered staff and endeared their support through collaboration.  However the capacity of kitchen staff to enact their intentions was problematic for some.

External support

Participants reported high levels of confidence in their skills even before the program. Rather than improving skills, participants identified that the benefit of the celebrity status of facilitators, supported by experts, was for motivation and as influential advocates for change.
I think she is a really good person to drive this kind of thing. It needs somebody of her stature, her media profile and stuff like this to raise awareness with what is going on and what is achievable and what’s not and this sort of thing in the aged care.  (Head Chef IP-3)

Ongoing peer- support

All of the participants elaborated on how ongoing peer-support during and after the program facilitated their motivation to progress change. Active participation in a closed, social media group mediated by the Foundation was reported as facilitating and sustaining motivation and change. Participants shared photos of recipes, problems, solutions and advice. Some participants extended this support by making their facility available for visits and helping each other with events. Others were less active but monitored the posts regularly.
I get on there every night to see if somebody has cooked something different or if somebody has other comments.  (Head Chef IP-9)
The comradely, willingness to support each other and common ambitions and concerns, unified the participants as a community.
It’s ongoing and you feel important because you’re still part of it (Chef Manager IP-23)

Constraints to Enacting Change

Local-level structural constraints

Caveats such as costs, time constraints and food regulations were factors expressed by most participants as barriers to enacting change. Ingredients for the NH recipes were identified as costly and difficult to access, particularly as they were unavailable on the procurement lists negotiated for the state of Victoria and therefore not cost-competitive. Compounding this difficulty was the limited budget for meals per resident per day.
…….. the one nagging little thought in the back of my mind was that, yeah this is wonderful and we would love to do it but where is the money to do it …. the first moment they get the final  results back they have been told  “ooooh oooooh” this is costing us money so you better scale it back. (Manager Chef, IP-4)
Some participants attributed the restrictive budget to prioritizing costs rather than residents’ satisfaction.  Providing higher quality foods, more foods familiar to residents, more freshly sourced foods and foods to meet modified texture needs or specific nutritional needs of residents would incur additional costs beyond the set budget.
.. So you have got people making decisions based on the dollar rather then what is right for the kitchen, well what is the right care.  So this is where it has to change, the focus has to be on the care and food not the dollar; it should be secondary but not primary. (Food Service Manager IP-5)
Moreover, more than half of the participants identified that they needed more time sanctioned from management to rework recipes and redevelop menus. Support from NH management to develop new recipes, have the time to implement menu changes and change food service practices were identified as crucial to enabling participants. Also, a source of frustration was that some kitchen staff was resistant to change. Participants perceived this as; some staff not caring, some not seeing the relevance of changing, some entrenched in their ways and some not skilled or constrained by time and other workload demands.
..when I first started in aged care, you know it was just sort of nobody really cared. [The chef] had been here nearly 20 years and he was doing things the same way the day he left as the day he started and he couldn’t see an issue with that.  . (Head Chef IP-3)

System-wide constraints

Working within the national food regulations for aged care facilities were identified as a constraint by a few participants. Including more food variety and fresh ingredients was perceived as problematic given current food regulations which participants interpreted as increasing food contamination risk. Regulations also constrained some due to an uncertainty that they weren’t complying and favoured food wastage due to a rigid interpretation of the food safety regulations.
What is right? Not just someone saying they are taking the hardest line just to cover themselves (Food Services manager IP-5).
Some participants attributed different regulations between states, a lack of products on state-wide procurement lists and different interpretations of the food regulations by auditors and food service providers as barriers to enacting menu changes.
Participants elaborated that the time demands of providing meals were exacerbated by significant reforms within the aged care sector as facilities expanded to accommodate the ageing population.  Some participants also reflected concerns for finding time to develop menus for the next generation of ‘baby boomers’ with different food preferences and the pressure of implementing consumer-directed care where people will have more control and choice over the services provided.
We are introducing this household module more so the nurses will be doing more, so that’s putting a lot of stress on everyone. … That’s where I am finding it hard. That’s where you get burnt out you know. (Support Services Manager IP-8)
A few others perceived aged care reform as disempowering foodservice further where the priority is given to nursing care, cost-savings are sought from foodservices and food services are not considered part of the care team despite the importance of food to residents.
In contrast, aged care reform was also identified as an opportunity including possibly changing the role of food services from a support service to part of the care team
But we have people in business background now coming in, in charge of aged care facilities, this is a really positive change because they actually …. think of aged care facilities as hotels, with super services being a very important part, food being a very important part… (Manager Chef, IP-4)
Key enablers and constraints shared by the participants are summarised in Table 2.

Table 2
Barriers and enablers identified by senior food service providers (n=23) from Nursing Homes (n=21) in Victoria, Australia, four months after attending an education intervention

Barriers and enablers categorized according to three levels of influence as described in socio-ecological model for health behavior changes (29)

 

Discussion

Efforts to change or strengthen practices in NH food services must carefully consider food service providers’ motivations and perceived barriers and enablers. Empathy for residents, wanting to make a difference to people’s QOL and achieving high standards of service were all expressed as motivations in this study, which is absent in the literature. Within their facilities, senior foodservice providers appear to have the agency to make changes with management’s support and an inspired and skilled food service staff.  Local level factors such as meal costs, scheduled time and staff engagement were identified by participants as enablers or constraints. Quantitative studies have also acknowledged costs, time and staff resistance as significant barriers to enacting change in NH food services (20, 21).
In this study, celebrities supported by experts acted as the catalyst for change. Rather than increasing participants’ skills, their contribution was to increase participants’ self-efficacy to become change agents and their perceived influential standing with management and beyond. Celebrity chefs are recognized to enable changes in food services (22) and the popularity of celebrity chefs in food programming is well known to the public (23, 24). Also crucial was that the intervention acted as a conduit for isolated senior-level chefs to work together as a community. Learning as a community of practice is a well-known pedagogical approach (25) however it needs to be guided. Peer support is also well known as an enabler for supporting change (26) although there is a scarcity of this in the literature for NH.
While enablers such as external peer-support, organizational support and increased self-efficacy empowered chefs to enact local-level changes, barriers beyond the influence of individuals presented significant constraints. These included benchmarks for meal costs, restrictive state-wide procurement lists, subjective local food regulations and a lack of national NH food standards, all of which require system changes.
Difficulties sourcing affordable ingredients flagged the need for changes to the state’s procurement processes whereby many facilities are limited to purchasing products on this competitively-priced list. Likewise, discussions at the system level were called for regarding food regulations.  The safety of residents and protection from food contamination is paramount but some food service staff struggle with interpreting and using the regulations (12) and widening the scope for the use of more ‘home-style’ recipes made from fresh ingredients.
Similarly, a significant constraint was the lack of a minimum budget benchmark for meals per resident per day. Local benchmarks covered the minimum requirement for three meals per day plus mid-meals but were a barrier to introducing more variety, more choice, more acceptable modified textured meals and more fresh ingredients. These qualities have been correlated with residents’ satisfaction (11, 12, 27) which in turn influences QOL and nutritional status (6, 9, 17). Research is required to demonstrate whether meals which meet the nutritional needs of residents while satisfying other needs for ‘good food’ can be achieved at only a small cost increase or cost neutral with savings created from improved health outcomes.
National standards for food services in NH would justify minimum benchmarks for costing meals plus minimum requirements for nutritious meals recognized as ‘good food’ (11) that also contributed to residents’ QOL and enjoyment (8, 9). Australia does not have national food service standards for NH although most of the states and territories have developed voluntary standards for publically-funded facilities.
The issue of cost raised questions about the role of food services in NH. Some participants stated that the care of residents rather than the budget should drive decisions about food services. The low prioritization of food services in Australia is an issue in other studies (12, 20) and its perceived relegation to hotel services or support services means that outcomes are based upon meeting budgetary projections and volume of meals rather than being part of holistic care. Participants recognized that the food provided had a direct impact on residents’ satisfaction and QOL. Moreover, food service staff that interacted with residents noted that they were a channel for residents’ concerns and part of residents’ social lives. This phenomenon where commensality and social-interactions in NH influences residents’ QOL is well known (8, 10, 14). Some participants elaborated further that food services should be considered part of the care team rather than an adjunct support service. Participants’ motivation was predominately to improve the QOL of residents through food, and elevating food service management to be part of the care team would empower what is a traditionally disempowered group (20). Due to their celebrity-status and wider influence, and in the absence of a peak body for NH food services, participants believed that entities such as the Foundation have the potential to initiate discussions for system changes to support the transformation of aged care food services.

Practice Implications and Study limitations

While studies have explored the perceptions and experiences of residents and of care staff with NH food provision, this study focused on food service providers and is the first to the authors’ knowledge.  These results highlight the importance of including food service providers’ frontline experiences with enacting change and using this information on identified gaps, barriers and enablers to augment intervention planning. Food service staff providing ‘good food ‘which is consistent with national regulations face unique challenges (28). Enablers included being empowered by the attention of celebrity-led advocates, attending an educational program, ongoing peer support across NH and organizational support. Study findings are consistent with a socio-ecological perspective that presumes that human behaviour is a result of the interaction of environmental factors and individual characteristics (29). At the individual level foodservice providers would benefit from ongoing peer support as a community of practice, participation in a program that builds capacity to enact change rather than build foodservice knowledge and skills and stronger collaboration with upper management.  At the wider levels of influence, system-wide changes would benefit such as; national standards for NH food services, national benchmarking for costing meals, an expansion of the definition of nutritious, appropriate foods to include ‘good food’ and a revisit of national NH national food regulations and state-wide procurement lists as to how they are interpreted and enacted. From this study, reconsidering food services as part of the care team also appears warranted as aged care expands and more is known about the interface between residents’ QOL and food service providers.
Despite the range of NH types, sizes and geographical location there was commonality in what interviewees shared and saturation with no new themes or information from the analysis. However, a limitation of this study is that while qualitative research provides rich in-depth data, it cannot be generalized and the participants were likely to have been early adopters and not representative of all NH.  Given the universal importance of nutritious food provision in nursing homes and the central role of food service providers for residents’ food satisfaction and QOL, this warrants more research for generalisability.

 

 

Conclusion

Incorporating strategies that address the barriers and incorporate the enablers identified by senior food service providers are critical for successful interventions and change in NH. Within their facilities, food service providers have the agency to make changes with management’s support and a motivated food service staff. External enablers such as ongoing peer-support and attention from celebrity-status experts increase the self-efficacy of food service providers and empower them to enact the changes they are very motivated to do. The education part of the intervention and skill development is not central. Other factors, however, are beyond individual’s agency and require a systems approach. National benchmarks and standards for food regulation, meal-costing and ‘good food’, complemented with a change in role from support to care would enable this disempowered group.  This study has relevance to program developers but also to policymakers interested in enacting national regulations and system changes which ensure residents’ enjoyment of food, QOL and health.

 

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. All of the authors have nothing to disclose.

Acknowledgements: The authors wish to acknowledge the partnership with the not-for-profit Maggie Beer Foundation (MBF), particularly Maggie Beer, who engaged Flinders University to evaluate their national educational program. The MBF developed and delivered the ‘Creating an Appetite for Life’ programs in collaboration with food service experts and accredited foodservice dietitians. The MBF had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.

Conflict of interest: The authors including Professor Michelle Miller, Ms Olivia Farrar, Ms Jude Hamilton and Ms Louisa Matwiejczyk have no conflict of interests to disclose.

Ethical standards: Approval for the study was granted by the Social and Behavioral Research Ethics Committee at Flinders University South Australia.

 

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